Basic Information
| Provider Information | |||||||||
| NPI: | 1295025716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LONG | ||||||||
| FirstName: | RACHAEL | ||||||||
| MiddleName: | OLIVIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 EXCELSIOR BLVD | ||||||||
| Address2: | SUITE 160 | ||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554264744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529937711 | ||||||||
| FaxNumber: | 9529936798 | ||||||||
| Practice Location | |||||||||
| Address1: | 9300 NOBLE PKWY N | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554435500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632365300 | ||||||||
| FaxNumber: | 7632365250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2011 | ||||||||
| LastUpdateDate: | 11/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 55362 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.